Common Reasons for Claim Denials

Why Am I Being Denied Benefits?

The attorney must undertake a detailed case analysis to develop a strategy for decision making and pre-empt the expected review which will be employed by the carrier. Many times clients have handled their own applications and appeals in a manner that is not effective against a comprehensive and aggressive claim reviewer. These houses of cards are knocked over with a feather. A good foundation and solid claims construction is necessary to withstand aggressive claims processing.

The following is a list, in no specific order, based on our law firm’s experience of the most often cited reasons for claim denials:

denial issued with no statement of the specific reasons for the denial

changing basis for denial; follow the bouncing ball

not disabled within the Elimination Period

onset of disability did not occur while policy was in force

“Not under the regular care of physician,” or wrong type of care-“not appropriate care” or “no in-person treatment”

no “objective evidence of disability”

“symptoms are merely self –reported” no objective evidence of the degree and frequency of the symptoms – OFTEN seen in MS cases

condition is amenable to treatment or claimant is not compliant or can work with treatment, medications etc…

no change in condition from when claimant was working with the impairment

prescription/pharmacy records “do not support amount of medication claimant reports taking” or “document that claimant averages X pills per day which would not cause symptoms alleged” or “do not document any changes in medications or dosages to support claimant’s alleged worsening of condition”

disable due to mental/ nervous and 24 month provision is invoked

not a true disability, but a personality trait not amenable to treatment

job not occupation; not disable from “own occupation” only disabled from job as they performed it

can do all the “material duties” of occupation or job

occupation “at time of disability” – claimant modified the occupation and kept working or just supervised and waited to file

claimant was “dually employed” as Y & Z and can perform Z; able to perform the material duties of occupation or job Z even though cannot perform Y

“misrepresentation by claimant” of income, job description or medical history or failure to disclose excessive disability coverage when clearly not the case

condition did not “first manifest” “while policy was in force”

failure to provide “timely notice” of claim as specified

review by their VE; can perform some material duties or dispute over the “material dutiesof job or occupation,” “what is job or occupation”

review by their experts who question severity of symptoms, claimant’s motivation, credibility or establish disability as of onset date that precludes benefits

IME or Peer Review or Peer to Peer phone call supported denial

nothing has changed; claimant worked previously with impairment and no change in condition is supported by objective medical evidence in record

denials based on PI surveillance denials, claimant was seen or recorded…; visit by field representatives to claimant’s home documented…; credit card charges showed frequent trips out of town (you can fly, you can work denial)

SS games: client not found disabled by SS; client’s SS decision states that most significant impairment is X and we only cover Z or coverage for X is limited to 24 months; non-examining, non-treating State Agency doctor agrees with assessment of insurance company; found disabled by SS but SS had different or incomplete information – not reliable determination.

ERISA applies

failure to exhaust administrative remedies

evidence not presented timely to plan administrator; not part of claim file prior to exhaustion of administrative process